THE LONG WAIT FOR MENTAL HEALTH COVERAGE

Saturday

Sep 28, 2013 at 12:01 AMSep 28, 2013 at 5:45 AM

c.2013 New York Times News Service

c.2013 New York Times News Service

The first time Melissa Morelli was taken to the hospital, she was suicidal and cutting herself, her mother says. She was just 13, and she had been transferred to a psychiatric hospital, where she stayed for more than a week. Her doctors told her mother, Cathy Morelli, that it was not safe for Melissa to go home. But the family’s health insurance carrier would not continue to pay for her to remain in the hospital.

The second time, the same thing happened. And the third and the fourth. Over the course of five months, Cathy Morelli took Melissa to the hospital roughly a dozen times, and each time the insurance company, Anthem Blue Cross, refused to pay for hospital care.

“It was just a revolving door,” Morelli said.

“You had not been getting better in a significant way,” Anthem explained in one letter sent directly to Melissa, then 14, in July 2012. “It does not seem likely that doing the same thing will help you get better.”

Desperate to get help for her daughter, Morelli sought the assistance of Connecticut state officials and an outside reviewer. She eventually won all her appeals, and Anthem was forced to pay for the care it initially denied. All told, Melissa spent nearly 10 months in a hospital; she is now at home. Anthem, which would not comment on Melissa’s case, says its coverage decisions are based on medical evidence.

Melissa’s treatment did not come cheap: It ultimately cost hundreds of thousands of dollars, Morelli said. Patients often find themselves at odds with health insurers, but the battles are perhaps nowhere so heated as with the treatment of serious mental illness.

It was not supposed to be this way. A federal law, the Mental Health Parity and Addiction Equity Act of 2008, was aimed at avoiding fights like this over coverage by making sure insurers would cover mental illnesses just as they cover treatment for diseases like cancer or multiple sclerosis.

Long a priority of Sen. Edward M. Kennedy of Massachusetts, it was squeezed into a bank bailout bill with the help of Christopher J. Dodd, then a Democratic senator from Connecticut, after Kennedy learned that he had brain cancer, which turned out to be fatal. The law requires larger employer-based insurance plans to cover psychiatric illnesses and substance-abuse disorders in the same way they do other illnesses.

But five years after President George W. Bush signed the law, there is widespread agreement that it has fallen short of its goal of creating parity for mental health coverage.

As enrollment in coverage under the Affordable Care Act becomes available Tuesday, the rules underlying mental health coverage in general — for both private insurers and the new health care exchanges — are still unclear, mental-health patient advocates say, leaving patients and families to grind through the process as best they can.

Deciding how mental illness should be treated — and at what cost — is no easy matter. Unlike some physical ailments for which there are reams of studies suggesting a relatively clear standard of care, there is often little accepted medical evidence to support the range of treatments for many mental illnesses, like schizophrenia and severe depression.

“It’s very different from the approach to a bypass procedure or a hip replacement,” said Karen Ignagni, the CEO of America’s Health Insurance Plans, a trade association representing the nation’s health insurers.

At issue is not coverage for run-of-the-mill care like prescription medications for depression or a few visits with a therapist. Insurers generally cover these costs the same way they cover medications for, say, high blood pressure.

But when patients need months of residential care, for example, or meetings with a therapist several times a week, insurers balk. The insurance executives say that the medical benefits of such treatments are not clear and that the industry is essentially being asked to write a blank check.

Mental health accounts for a small part of total health care spending — by one estimate, $113 billion annually, or less than 6 percent of the $2.6 trillion overall health care bill. But pressure is intensifying on insurers under the Affordable Care Act, which includes mental health care as an essential benefit, because they are already trying to keep the premiums they charge for plans on the new state marketplaces as low as possible. Insurers are concerned about the potential for new costs, while patient advocates worry that mental health will be neglected.

Both sides say Washington is partly to blame. The federal government has yet to write the mental health act’s final regulations for insurance companies, leaving a crucial gap between the intent of the measure and how it actually works.

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Kennedy’s son, Patrick J. Kennedy, the former congressman from Rhode Island who was one of the law’s main backers, said he worried that the Obama administration had delayed the rules because officials were preoccupied with the president’s broader legislation and needed the insurance companies’ support.

President Barack Obama “needs the private insurers to implement this law or it’s not going to work,” said Patrick Kennedy, who has talked openly about his struggles with depression and bipolar disorder. He has held hearings on mental health issues across the country to talk to patients and their families, including one earlier this year where Cathy Morelli spoke.

Insurance companies, for their part, say they would welcome final rules under the 2008 law.

“We think it may create better clarity,” said a spokeswoman for Aetna, which says it fully supports the 2008 parity law.

The administration says it will draft the rules by year-end. While the act was clear about preventing insurers from setting strict time limits on treatment, it is vague about how parity is to be achieved. The most contentious areas are intensive treatments at a doctor’s office or clinic as well as potentially lengthy hospital stays. If an insurer does not typically limit outpatient medical treatments, for example, there is debate over what standard it can then apply to outpatient therapy sessions that could go on for months, if not years. It is those kinds of details that the final rules are expected to address.

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Like many others, Cathy Morelli fought for a child’s care outside of the courts, but some patients and their families have filed lawsuits against large insurance companies. And they cite the 2008 law.

Jonathan Denbo, the director of marketing for CBS Sports Network, filed a lawsuit against the UnitedHealth Group earlier this year. Denbo, who had generalized anxiety disorder, began seeing a therapist twice a week after his mother died. The sessions cost $250 each, according to his lawyer. Last year, UnitedHealth told him that it would no longer cover his treatment, saying that he was “generally functioning quite well” and that he should be able to manage his condition on his own or through community resources, according to the suit.

“The use of multiple weekly therapy sessions is limited to acute exacerbations of illnesses or in the context of a clinical urgent situation in order to prevent a higher level of care,” UnitedHealth said in a letter sent to Denbo.

The psychotherapist for Denbo said UnitedHealth was violating the mental health law because, under the employer’s plan, the insurer does not require prior approval of out-of-network outpatient care. Denbo declined to be interviewed for this article. He and other patients are plaintiffs in a federal lawsuit against UnitedHealth that is seeking class-action status.

In another case from the same lawsuit, Brad Smith, a marketing associate at the Seattle subsidiary of Sysco, a food products distributor, was urged to consider residential treatment for his teenage son, who was suffering from severe depression. Last March, the young man was involuntarily hospitalized at the Eastern Idaho Regional Medical Center, where the staff recommended residential treatment.

UnitedHealth agreed but then stopped paying for the care nine days after the young man was admitted. In its letter to the boy’s parents, UnitedHealth said stopping the treatment created only “limited risk” that the teenager would return to the hospital. There is “no expectation of further improvements in the shorter term,” the letter said, suggesting that it would not pay for care that would not result in his getting better anytime soon.

Smith nonetheless continued with his son’s care and, he says, he and his former wife have spent $100,000 trying to help him.

“I’m currently way over my head in debt,” he said.

He recently sold his house at a $31,000 loss. He now lives with his sister. His son came home in August, and Smith says he thinks the treatment was successful.

“It was, oh my God, we’ve got this kid back,” he said.

The idea that UnitedHealth would cover care only if patients could show that their conditions were likely to worsen without it represents a clear double standard, said D. Brian Hufford, the lawyer representing plaintiffs in the UnitedHealth case.

Hufford is seeking a preliminary injunction for some of his clients, who, like Smith, cannot afford to pay for continuing treatment.

UnitedHealth declined to comment on the lawsuit, which it is seeking to have dismissed. UnitedHealth says that it uses case managers to help patients find alternatives when it will not pay for certain treatments and that it is pushing for additional research into what treatments are effective.

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Regulators have also raised concerns. In another case that is not part of a lawsuit, and which involves a young woman from California, Anthem Blue Cross cut off benefits for residential care after five days. The facility temporarily placed the woman in a conference room.

“I was very confused the whole time,” said the woman, whose parents hired an expert to help appeal the Anthem decision. An independent review, authorized under state law, found that Anthem had to cover the treatment. Anthem tried to deny the care again but was overruled.

The cost of her treatment was around $100,000. Regulators concluded that Anthem did not comply with the state’s insurance law, which is similar to the federal act. Anthem declined to comment.

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Determining what the 2008 law requires “is challenging,” said Brent A. Barnhart, the director of the California Department of Managed Health Care, one of two regulators overseeing health insurance in the state.

In late June, Barnhart’s department fined the state’s largest health plan, run by Kaiser Permanente, $4 million for deficiencies that limited access to mental health care under California law. In one location, the state found a website that seemed to indicate members could not get care if they had a “chronic mental illness.”

“What we found was they were falling way, way short,” Barnhart said. “The fine was intended as a wake-up call.”

Kaiser, which says it is has addressed the department’s concerns, said it was in discussions with the agency about the fine.

Barnhart said he worried that other plans might also make it hard for people to get treatment.

Insurers, he said, seem to continue to view mental health as “secondary to all other health.”